Automatic Donation Application
DONOR ENROLLMENT FORM
Last First
Name Name M.I.
Address Phone
City State Zip __
Bank Branch
City State Zip
Amount of authorized debit (withdrawal): $____________________
Withdrawal
Period (circle one): Monthly
Quarterly (Feb, May, Aug, Nov) Annually (Month):
Date
of Withdrawal (circle one): 1st 15th Allow 5 business days for processing.
I
(we) hereby authorize the Charitable Partnership Fund (CPF) to initiate debit
entries to my (our) account described on this form, at the Bank identified on
this form, and to debit the same to such account. SUCH
DEBITS ARE TO BE MADE FOR THE BENEFIT OF the
Arizona Cat Assistance Team, Inc. (dba AzCATs), hereinafter called RECIPIENT, to be paid to
RECIPIENT in the manner and times as agreed from time to time between CPF and
RECIPIENT.
This
authority will remain in effect until I (we) notify the appropriate parties of
changes in such time as to allow the Bank a reasonable time to act on
the notification. Requests for termination in
this program, or for reductions in contribution amounts, should be made to
RECIPIENT who will forward to CPF. Requests for increases in
contribution amounts, or any notice of changes to account information, must be
submitted in writing, accompanied by date and
signature(s), to RECIPIENT who will forward to CPF. I
(we) understand that while I (we) submit requests for changes regarding
my (our) participation in this program to RECIPIENT, final responsibility for
notifying CPF of any changes lies with me (us), the donor(s).
I
(we) can stop payment of an entry by notifying my (our) financial institution
three (3) days before my account is charged.
I (we) understand that if RECIPIENT is not qualified as a public charity, or otherwise does not satisfy distribution policies set forth by CPF, I (we) may identify another organization to serve as RECIPIENT. I (we) further understand that CPF has final authority over the entity that may serve as RECIPIENT, as set forth in CPF’s policies.
Signature Date
(co-owner) Signature Date